[Show abstract][Hide abstract] ABSTRACT: To investigate whether analgesic and sedative drug use during PICU treatment is associated with long-term neurodevelopmental outcome in children who survived meningococcal septic shock.
This study concerned a secondary analysis of data from medical and psychological follow-up of a cross-sectional cohort of all consecutive surviving patients with septic shock and purpura requiring intensive care treatment between 1988 and 2001 at the Erasmus MC-Sophia Children's Hospital. At least 4 years after PICU admission, these children showed impairments on several domains of neuropsychological functioning. In the present study, type, number, and dose of sedatives and analgesics were retrospectively evaluated.
Tertiary care university hospital.
Seventy-seven meningococcal septic shock survivors (median age, 2.1 yr).
Forty-five patients (58%) received one or more analgesic and/or sedative drugs during PICU admission, most commonly benzodiazepines (n = 39; 51%), followed by opioids (n = 23; 30%). In total, 12 different kinds of analgesic or sedative drugs were given. The use and dose of opioids were significantly associated with poor test outcome on full-scale intelligence quotient (p = 0.02; Z = -2.28), verbal intelligence quotient (p = 0.02; Z = -2.32), verbal intelligence quotient subtests (verbal comprehension [p = 0.01; Z = -2.56] and vocabulary [p = 0.01; Z = -2.45]), and visual attention/executive functioning (Trial Making Test part B) (p = 0.03; Z = -2.17). In multivariate analysis adjusting for patient and disease characteristics, the use of opioids remained significant on most neuropsychological tests.
The use of opioids during PICU admission was significantly associated with long-term adverse neuropsychological outcome independent of severity of illness scores in meningococcal septic shock survivors.
Pediatric Critical Care Medicine 12/2013; · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims of the study: This study aimed to evaluate if the microcirculation is impaired during and after therapeutic hypothermia (TH) in children with return of spontaneous circulation after cardiac arrest (CA) and to assess if microcirculatory impairment predicts mortality. This has been reported for post-CA adults, but results might be different for children because etiology, pathophysiology, and mortality rate differ.
This prospective observational cohort study included consecutive, non-neonatal post-CA children receiving TH upon intensive care admission between June 2008 and June 2012. Also included were gender-matched and age-matched normothermic, control children without cardiorespiratory disease. The buccal microcirculation was non-invasively assessed with Sidestream Dark Field Imaging at the start of TH, halfway during TH, at the start of re-warming, and at normothermia. Macrocirculatory, respiratory, and biochemical parameters were also collected.
Twenty post-CA children were included of whom 9 died. During hypothermia, the microcirculation was impaired in the post-CA patients and did not change over time. At normothermia, the core body temperature and the microcirculation had increased and no longer differed from the controls. Microcirculatory deterioration was associated with mortality in the post-CA patients. In particular, the microcirculation was more severely impaired at TH start in the non-survivors than in the survivors-positive predictive value: 73-83, negative predictive value: 75-100, sensitivity: 63-100%, and specificity: 70-90% Conclusions: The microcirculation is impaired in post-CA children during TH and more severe impairment at TH start was associated with mortality. After the stop of TH, the microcirculation improves rapidly irrespective of outcome.
[Show abstract][Hide abstract] ABSTRACT: Recent literature on paediatric status asthmaticus (PSA) confirms an increasing percentage of admissions to paediatric intensive care units. PSA is a medical emergency that can be fatal and needs careful and prompt intervention. The severity of PSA is mainly determined by clinical judgement of signs and symptoms. Peak flow measurements and serial lung function measurements are not reliable in PSA. Validated clinically useful instruments are lacking. The three main factors that are involved in the pathophysiology of PSA, bronchoconstriction, mucus plugging and airway inflammation need to be addressed to optimise treatment. Initial therapies include supplementation of oxygen, repetitive administration of rapid acting β2-agonists, inhaled anticholinergics in combination with systemic glucocorticosteroids and intravenous magnesium sulphate. Additional treatment modalities may include methylxanthines, DNase, ketamine, sodium bicarbonate, heliox, epinephrine, non-invasive respiratory support, mechanical ventilation and inhalational anaesthetics.
[Show abstract][Hide abstract] ABSTRACT: Severe acute asthma in children is associated with substantial morbidity and may require pediatric ICU (PICU) admission. The aim of the study was to determine risk factors for PICU admission.
The study used a retrospective multicenter case-control design. The cases included children admitted to the PICU because of severe acute asthma and a history of out-patient treatment by pediatricians or pediatric pulmonologists. Controls were children with asthma without a PICU admission for severe acute asthma. The children were matched for sex, age, hospital, and time elapsed since the diagnosis of asthma. Fourteen possible risk factors were analyzed.
Sixty-six cases were matched to 164 controls. In univariate analysis, all but one of the analyzed variables were significantly associated with PICU-hospitalization. After multivariate conditional logistic regression analysis, 4 risk factors remained significant. These included active or passive smoking, allergies, earlier hospitalization for asthma, and non-sanitized home.
Physicians and parents should be aware of these risk factors, and efforts should be made to counteract them.
Respiratory care 02/2012; 57(9):1391-7. · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate long-term psychosocial outcomes in young adults who survived septic shock caused by Neisseria meningitidis (meningococcal septic shock) during childhood.
A cross-sectional study.
The psychological investigation took place in the department of Child and Adolescent Psychiatry of the Erasmus MC-Sophia Children's Hospital.
All consecutive surviving patients with meningococcal septic shock requiring intensive care treatment at the pediatric intensive care unit between 1988 and 2001.
To explore biographical characteristics (such as living conditions, educational, occupational, and marital status) and illness-related physical or social consequences a structured interview was used. To assess intellectual functioning the Groninger Intelligence Test 2 was used and to assess behavioral/emotional problems, the Adult Self-Report was used.
Fifty-eight of 83 eligible septic shock survivors were evaluated (response rate: 70%). The patients were 16-31 yrs old at time of follow-up (median age: 21 yrs old). These patients had had meningococcal septic shock before 18 yrs of age. Median follow-up interval was 13 yrs, with a range of 4 to 16 yrs. For the vast majority of meningococcal septic shock patients, outcomes on biographical characteristics, intellectual functioning, and levels of behavioral/emotional problems were comparable to those of reference groups. A minority (5% to 20%) still report illness-related physical or social consequences, behavioral and emotional problems, and lower intellectual functioning.
Despite favorable outcomes for the majority of meningococcal septic shock patients in the long term, an important minority (5% to 20%) still struggles with ongoing problems as to behavioral/emotional problems, intellectual functioning, biographical characteristics, and illness-related physical or social consequences.
Pediatric Critical Care Medicine 04/2011; 12(6):e302-9. · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess psychological distress, styles of coping and disease-related psychosocial limitations in parents of children and adolescents who survived meningococcal septic shock (MSS) 4-16 years ago.
An exploratory design using standardised questionnaires and interviews.
The psychological investigation took place in the department of Child and Adolescent Psychiatry of the ErasmusMC-Sophia Children's Hospital.
87 mothers and 77 fathers participated in this study. The General Health Questionnaire was used to assess parents' psychological distress; the Utrecht Coping List to assess styles of coping. A semi-structured disease-specific interview served to explore long-term disease-related psychosocial limitations for parents.
MSS parents reported similar psychiatric symptoms and styles of coping in comparison to reference groups. Severity of illness and the child's age at time of illness were not significant predictors of parental psychological distress and styles of coping. The presence of somatic sequelae, cognitive or behavioural and emotional problems was not associated with the levels of parental psychiatric symptoms or styles of coping. The vast majority of parents reported no current disease-related psychosocial limitations due to the MSS.
Parents of children who survived MSS show recovery. Nevertheless a minority still experiences emotional burden and disease-related limitations.
Intensive & critical care nursing: the official journal of the British Association of Critical Care Nurses 02/2010; 26(3):128-37.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to evaluate associations between long-term physical and psychological outcome variables in patients who survived meningococcal septic shock (MSS) in childhood.
The study population was made up of all MSS patients requiring intensive care treatment between 1988 and 2001.
A total of 120 patients visited the follow-up clinic (age at paediatric intensive care unit (PICU) admission 3.1 years; follow-up interval 9.8 years; age at follow-up 14.5 years (all medians)). Four major outcomes were considered: 1) major physical sequelae (defined as major scars and/or orthopaedic sequelae) (29/120), 2) mild neurological impairments (39/120), 3) problem behaviour (defined as a total score above the 90th percentile of the reference groups on questionnaires to screen for psychopathology) (16/114) and 4) total intelligence quotient < 85 (18/115). No differences were found between patients with major physical sequelae and patients without major physical sequelae as to the presence of problem behaviour or total IQ < 85. Also, no differences were found between patients with mild neurological impairments and patients without as to the presence of problem behaviour or total IQ < 85. Finally, no differences were found between patients with major physical sequelae and patients without as to the presence of mild neurological sequelae. Less favourable scores on behavioural and emotional problems were significantly associated with poorer health-related quality of life (HR-QoL). HR-QoL scores were to a lesser amount predicted by severity of illness at time of PICU admission or by adverse physical outcome.
Long-term adverse physical and psychological outcomes in survivors of MSS did not seem to be associated. Poorer HR-QoL was mainly predicted by problem behaviour.
Critical care (London, England) 01/2010; 14(3):R124. · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the incidence of skin scarring and orthopaedic sequelae (amputation, limb-length discrepancy) in patients who survived meningococcal septic shock (MSS) in childhood and to determine the severity and predictors of these sequelae.
179 consecutive patients (170 of whom were eligible) with septic shock and purpura requiring intensive care between 1988 and 2001 in Rotterdam, the Netherlands were invited to visit a follow-up clinic 4-16 years after paediatric intensive care unit (PICU) discharge.
58 (48%) of 120 follow-up patients (median follow-up interval 10 years; median age at follow-up 14.5 years) had skin scarring due to purpura. This varied from barely visible to extremely disfiguring scars. Ten patients (8%) had undergone amputation(s) of extremities, ranging from one toe to both legs and one arm. Seven patients (6%) had lower limb-length discrepancy, in most cases together with angular deformity, requiring one or more late surgical intervention(s). Patients with scars or orthopaedic sequelae had significantly higher severity of illness scores, determined by the Pediatric Risk of Mortality score, Vasopressor score and Disseminated Intravascular Coagulation score. Gender or Neisseria meningitidis serogroup had no significant influence on the presence of scars or orthopaedic sequelae. Patients with lower limb-length discrepancy were significantly younger at the time of PICU admission.
The incidence of long-term skin scarring and orthopaedic sequelae was high (48% and 14%, respectively) in patients who survived MSS in childhood. The severity of these sequelae varied from mild to severe. Patients with scars or orthopaedic sequelae had significantly higher severity of illness scores.
Archives of Disease in Childhood 02/2009; 94(5):381-6. · 3.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess long-term health status in patients who survived meningococcal septic shock in childhood.
Medical and psychological follow-up of a cross-sectional cohort.
Pediatric intensive care unit (PICU) of a tertiary care university hospital.
All consecutive patients with septic shock and purpura who required intensive care between 1988 and 2001. Intervention Patients and their parents were invited to our follow-up clinic 4 to 16 years after PICU discharge.
Health status was assessed with a standard medical interview, physical examination, renal function test, and the Health Utilities Index Mark 2 (HUI2) and 3 (HUI3).
One hundred twenty patients (response rate 71%) participated in the follow-up (median age at PICU admission, 3.1 years; median follow-up interval, 9.8 years; median age at follow-up, 14.5 years). Thirty-five percent of patients had 1 or more of the following neurological impairments: severe mental retardation with epilepsy (3%), hearing loss (2%), chronic headache (28%), and focal neurological signs (6%), like paresis of 1 arm. One of the 16 patients with septic shock-associated acute renal failure at PICU admission showed signs of mild chronic renal failure (glomerular filtration rate, 62 mL/min/1.73 m(2); proteinuria; and hypertension). Scores were significantly lower on nearly all HUI2 and HUI3 attributes compared with Dutch population data, indicating poorer health in these patients.
In patients who survived meningococcal septic shock in childhood, one-third showed long-term neurological impairments, ranging from mild to severe and irreversible. Patients reported poorer general health as measured by HUI2 and HUI3.
[Show abstract][Hide abstract] ABSTRACT: To assess long-term cognitive functioning and its predictors, in children and adolescents who survived meningococcal septic shock (MSS) 4 to 16 years ago.
The Wechsler Intelligence Scale for Children-third edition was used to measure intellectual functioning and neuropsychological tests were used to measure attention, verbal memory, visual-motor integration, and executive skills.
Overall, results of the total MSS sample (N=77) as to neuropsychological functioning were similar to those of normative reference groups. On social and practical reasoning and visual-motor integration, however, MSS children obtained poorer outcomes compared to normative data. Two children had mental retardation (estimated IQ<70) due to the MSS. The percentage of children with mental retardation or borderline intellectual functioning (15%) was similar to that in the general population (16%). Eighteen children (23%) had a z score<-2, indicating unusual poor functioning, on one or more domains of neuropsychological functioning (selective attention, sustained attention, and executive functioning). Compared to normative data, significantly more children had received special education services in the past. Older age at time of follow-up was the most important significant predictor of poorer long-term cognitive functioning.
Overall, long-term outcomes as to cognitive functioning of the total MSS sample were similar to those of normative reference groups, but MSS children showed long-term impairments on social and practical reasoning, visual-motor integration, attention, and executive functioning. Older age at time of follow-up was a significant predictor.
British Journal of Clinical Psychology 12/2008; 48(Pt 2):195-208. · 1.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the occurrence of a wide range of behavioural, emotional, and post-traumatic stress problems in children and adolescents, long term after septic shock caused by Neisseria meningitidis (MSS).
This study included 6- to 17-year-old patients who survived MSS and were admitted to the PICU of the Medical Centre between 1988 and 2001. To assess behavioural, emotional, and post-traumatic stress problems, the Child Behaviour Checklist (CBCL), the Teacher's Report Form (TRF), and the Youth Self-Report (YSR) were used.
Parents of 89 MSS children, aged 6-17 years, completed the CBCL. Teachers of 65 same-aged MSS children completed the TRF, and 45 11- to 17-year-old MSS children completed the YSR. These data were compared with those from the normative reference groups.
Overall, the proportions of MSS children scoring in the deviant range for problem behaviour were comparable to the proportions in the reference groups, according to parents', teachers', and self-reports. As to the level of emotional and behavioural problems, mothers of the MSS children reported more somatic complaints regarding their children in comparison with the reference groups. Severity of illness was not a significant predictor of behavioural, emotional, and post-traumatic stress problems. Age at the time of illness was a significant predictor of behavioural, emotional, and post-traumatic stress problems in MSS children, indicating that the younger the child at the time of illness, the more problems were reported by parents at follow-up.
Overall, the results showed long-term behavioural, emotional, and post-traumatic stress outcomes for MSS children, which were comparable to those in the general population.
British Journal of Clinical Psychology 10/2008; 47(Pt 3):251-63. · 1.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To investigate self-esteem and its relation to scars, amputations, and orthopedic sequelae in children and adolescents long term after meningococcal septic shock (MSS) caused by Neisseria meningitidis.
The Dutch versions of the Self-Perception Profile for Children (SPP-C; 8-11 years) and the Self-Perception Profile for Adolescents (SPP-A; 12-17 years) were used to assess self-esteem. The Patient and Scar Assessment Scale (PSAS) was used to evaluate scar severity.
MSS boys aged 8-11 years achieved higher, more favorable scores on self-esteem, whereas same-aged MSS girls reported comparable levels of self-esteem compared with the respectively same-aged reference boys and girls. MSS boys and girls aged 12-17 years obtained unfavorable scores on self-esteem compared with respectively same-aged reference boys and girls. Overall gender did not have an effect on self-esteem. Severity of illness, age at time of illness, and age at time of follow-up were not significant predictors of self-esteem. MSS adolescents with scars reported lower global self-worth than MSS adolescents without scars. The worse MSS children evaluated their scars, the worse their outcomes on social acceptance. The worse MSS adolescents evaluated their scars, the worse their outcomes on close friendship, but the better their outcomes on social acceptance and behavioral conduct.
In this cross-sectional study, favorable outcomes for self-esteem were found in MSS children, whereas MSS adolescents reported lower self-esteem compared with reference adolescents. Adolescents with scars reported lower global self-worth than MSS adolescents without scars.
Journal of Adolescent Health 05/2008; 42(4):386-93. · 2.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess health consequences and health-related quality of life (HR-QoL) in children with meningococcal septic shock up to 2 yrs after discharge from the pediatric intensive care unit and to assess their parents. To determine major predictors of that outcome.
A prospective cohort study. Follow-up of all consecutive children with septic shock and purpura requiring intensive care treatment between 2001 and 2005, and their parents. HR-QoL was assessed with the Child Health Questionnaire (children) and Medical Outcomes Study 36-item Short-Form Health Survey (parents).
Of 53 eligible families, 47 participated (28 boys/19 girls; median age at the time of pediatric intensive care unit admission, 3.7 yrs; median Pediatric Risk of Mortality score, 21). A total of 26 children (55%) had scars as a result of skin necrosis; two (4%) had amputation of a digit or digits. In 21 children (45%), chronic complaints were reported. Children with and without chronic complaints did not differ significantly with regard to severity of illness and age at the time of pediatric intensive care unit admission. Significantly lower scores were found on HR-QoL scales concerning mainly physical functioning and health perception in comparison with normative data. There was a significant negative association between severity of illness and the HR-QoL scale concerning physical functioning. Children with chronic complaints had significantly lower scores on the HR-QoL scale concerning pain. Eight of 47 mothers (17%) at the time of the study had anxiety or depression requiring professional help. Mothers with and without these problems differed significantly with regard to age of their child at the time of pediatric intensive care unit admission. Parents showed significantly higher scores on HR-QoL scales concerning physical functioning and bodily pain in comparison with normative data. There was a significantly negative association between the presence of emotional problems and HR-QoL scores in mothers.
Up to 2 yrs after discharge from the pediatric intensive care unit, there is still a considerable effect on health and HR-QoL in children, especially on the physical scales. Severity of illness and chronic complaints negatively affected HR-QoL scales in children. Quite a few mothers suffered from emotional problems.
Critical care medicine 03/2008; 36(2):596-602. · 6.37 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess long-term health-related quality of life (HR-QoL) in patients who survived meningococcal septic shock in childhood, and their parents.
All consecutive patients with meningococcal septic shock requiring intensive care treatment between 1988 and 2001, and their parents. HR-QoL was assessed by the Child Health Questionnaire and the SF-36. Scores were compared with reference data of Dutch general population samples. Lower scores indicated poorer HR-QoL, higher scores more favourable HR-QoL.
One hundred and forty-five patients (response rate 82%) agreed to participate (age PICU admission 3.5 years; follow-up interval 10 years; age follow-up 14.6 years (all medians)). In patients, regardless of age and of patient- versus parent-report, significantly lower scores were found mainly on physical (physical functioning, general health perception) domains and/or physical summary score. In patients <18 years, according to parent-reports, significantly lower scores were also found on psychosocial HR-QoL domains, whereas in patients > or =12 years, according to patients themselves, significantly higher scores were found on psychosocial domains. As to parents themselves, we found significantly higher scores on the majority of HR-QoL scales (both physical and psychosocial).
In patients who survived meningococcal septic shock in childhood significantly lower HR-QoL scores were found on the physical domains. This could indicate that the patient's disease episode and present health status had a negative impact on their present physical HR-QoL. Overall long-term HR-QoL in parents was significantly higher.
Quality of Life Research 12/2007; 16(10):1567-76. · 2.41 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To gain insight into factors that might affect results of future case-control studies, we performed an analysis of children with sepsis and purpura admitted to the paediatric intensive care unit (PICU) of Erasmus MC-Sophia Children's Hospital (Rotterdam, The Netherlands).
Between 1988 and 2006, all 287 children consecutively admitted with sepsis and purpura were included in various sepsis studies. Data regarding age, gender, ethnicity, serogroup of Neisseria meningitidis, severity, therapy, and survival were collected prospectively. These data were pooled into one database and analyzed retrospectively.
The case fatality rate (CFR) from sepsis and purpura was 15.7%. During the study period, survival improved significantly. Younger age was significantly associated with more severe disease and a higher CFR. Children under the median age of 3.0 years had an increased risk of case fatality (odds ratio 4.3, 95% confidence interval 2.1 to 9.2; p < 0.001). Gender was not associated with CFR. However, males did have higher Paediatric Risk of Mortality scores, fewer PICU-free days, and more presence of shock. The course of sepsis and purpura was not related to ethnic origin. A causative organism was isolated in 84.3% of cases. N. meningitidis was the major organism (97.5%). Although N. meningitidis serogroup B was observed more often in younger children, serogroups were not associated with severity or survival. During the study period, the use of inotropic agents and corticosteroids changed substantially (less dopamine and more dobutamine, norepinephrine, and corticosteroids).
Age and gender are determinants of severity of paediatric sepsis and purpura. Survival rates have improved during the last two decades.
Critical care (London, England) 02/2007; 11(5):R112. · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To assess the effect of administration of sodium bicarbonate on carbon dioxide levels in children with life-threatening asthma (LTA) and to evaluate the clinical effect of this treatment. Study
A pediatric ICU (PICU) of a tertiary care university hospital.
Seventeen children with LTA who received sodium bicarbonate.
In January 1999, a new protocol for the treatment of LTA was initiated in our institution, incorporating the use of IV sodium bicarbonate in acidotic patients (pH < 7.15) with refractory status asthmaticus. Since January 1999, sodium bicarbonate was administered to 17 patients; 5 patients received two or three doses of sodium bicarbonate. In three patients, sodium bicarbonate was administered after intubation. Intubation and mechanical ventilation were performed in five patients before admission to the PICU, and in one patient during admission. There was a significant decrease of Pco(2) after sodium bicarbonate infusion (p = 0.007). An improvement of respiratory distress in all but one patient was seen as well.
Administration of sodium bicarbonate in 17 children with LTA was associated with a significant decrease in Pco(2) and an improvement of respiratory distress. The possible benefits of sodium bicarbonate in LTA deserve further study in a controlled, prospective design.